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Al-Hassany L, Lyons HS, Boucherie DM, Farham F, Lange KS, Marschollek K, Onan D, Pensato U, Storch E, Torrente A, Waliszewska-Prosół M, Reuter U. The sense of stopping migraine prophylaxis. J Headache Pain 2023; 24:9. [PMID: 36792981 PMCID: PMC9933401 DOI: 10.1186/s10194-023-01539-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Migraine prophylactic therapy has changed over recent years with the development and approval of monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway. As new therapies emerged, leading headache societies have been providing guidelines on the initiation and escalation of such therapies. However, there is a lack of robust evidence looking at the duration of successful prophylaxis and the effects of therapy discontinuation. In this narrative review we explore both the biological and clinical rationale for prophylactic therapy discontinuation to provide a basis for clinical decision-making. METHODS Three different literature search strategies were conducted for this narrative review. These include i) stopping rules in comorbidities of migraine in which overlapping preventives are prescribed, notably depression and epilepsy; ii) stopping rules of oral treatment and botox; iii) stopping rules of antibodies targeting the CGRP (receptor). Keywords were utilized in the following databases: Embase, Medline ALL, Web of Science Core collection, Cochran Central Register of Controlled Trials, and Google Scholar. DISCUSSION Reasons to guide decision-making in stopping prophylactic migraine therapies include adverse events, efficacy failure, drug holiday following long-term administration, and patient-specific reasons. Certain guidelines contain both positive and negative stopping rules. Following withdrawal of migraine prophylaxis, migraine burden may return to pre-treatment level, remain unchanged, or lie somewhere in-between. The current suggestion to discontinue CGRP(-receptor) targeted mAbs after 6 to 12 months is based on expert opinion, as opposed to robust scientific evidence. Current guidelines advise the clinician to assess the success of CGRP(-receptor) targeted mAbs after three months. Based on excellent tolerability data and the absence of scientific data, we propose if no other reasons apply, to stop the use of mAbs when the number of migraine days decreases to four or fewer migraine days per month. There is a higher likelihood of developing side effects with oral migraine preventatives, and so we suggest stopping these drugs according to the national guidelines if they are well tolerated. CONCLUSION Translational and basic studies are warranted to investigate the long-term effects of a preventive drug after its discontinuation, starting from what is known about the biology of migraine. In addition, observational studies and, eventually, clinical trials focusing on the effect of discontinuation of migraine prophylactic therapies, are essential to substantiate evidence-based recommendations on stopping rules for both oral preventives and CGRP(-receptor) targeted therapies in migraine.
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Affiliation(s)
- Linda Al-Hassany
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hannah S. Lyons
- grid.6572.60000 0004 1936 7486Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Deirdre M. Boucherie
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Fatemeh Farham
- grid.411705.60000 0001 0166 0922Department of Headache, Iranian Centre of Neurological Researchers, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kristin S. Lange
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Karol Marschollek
- grid.4495.c0000 0001 1090 049XDepartment of Neurology, Wroclaw Medical University, Wrocław, Poland
| | - Dilara Onan
- grid.14442.370000 0001 2342 7339Spine Health Unit, Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey ,grid.7841.aDepartment of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Umberto Pensato
- grid.417728.f0000 0004 1756 8807Neurology and Stroke Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy ,grid.452490.eHumanitas University, Pieve Emanuale, Milan, Italy
| | - Elisabeth Storch
- grid.6363.00000 0001 2218 4662Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Angelo Torrente
- grid.10776.370000 0004 1762 5517Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Marta Waliszewska-Prosół
- grid.4495.c0000 0001 1090 049XDepartment of Neurology, Wroclaw Medical University, Wrocław, Poland
| | - Uwe Reuter
- Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Universitätsmedizin Greifswald, Greifswald, Germany.
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Iannone LF, Fattori D, Marangoni M, Benemei S, Chiarugi A, Geppetti P, De Cesaris F. Switching OnabotulinumtoxinA to Monoclonal Anti-CGRP Antibodies in Drug-Resistant Chronic Migraine. CNS Drugs 2023; 37:189-202. [PMID: 36656298 DOI: 10.1007/s40263-022-00983-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND OnabotulinumtoxinA (BTX-A) and anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies (anti-CGRP mAbs) are approved drugs for chronic migraine (CM), a difficult-to-treat condition. Optimization of CM patient management by choosing the best options and determining appropriate time for switching or adding concomitant treatments are highly needed. OBJECTIVE Evaluate clinical response to anti-CGRP mAbs in patients who switched from BTX-A due to ineffectiveness defined by different cut-offs and assess the retention rate, effectiveness, and safety of both drugs within the first 9 months of treatment. METHODS A monocentric, cohort study, enrolling patients with CM, resistant to several preventive treatments, first treated with BTX-A and then with anti-CGRP mAbs with two observational phases of 9 months preceded by respective baseline. First, the retention rate and effectiveness of both treatments were measured in all patients. A second analysis assessed effectiveness in patients stratified according to <50 or <30% response rate to BTX-A. The absolute change from baseline in monthly headache days (MHDs), response rate, analgesic use, and persistence in medication overuse (MO) at 3, 6, and 9 months of treatment were recorded. Last observation carried forward (LOCF) analyses, including all patients and assuming no further changes after discontinuation, were performed for all outcomes. RESULTS Of the 78 enrolled patients (80.8% female, and 89.7% with MO at baseline), 32 (41.0%) received erenumab, 32 (41.0%) galcanezumab, and 14 (18.0%) fremanezumab. Retention rate was 62.2 and 91.0% for BTX-A and 76.9 and 96.2%, for anti-CGRP mAbs at 3 and 9 months of treatment, respectively. At 9 months of treatment, 22.4% of BTX-A patients and 65.0% of anti-CGRP mAbs patients achieved a ≥50% response rate. Anti-CGRP mAbs reduced MHDs, AMN, and AMDs, and decreased the number of MO patients at 9 months. In patients stratified according to <50 or <30% response rate to BTX-A, response rate (≥50% response at 9 months) to anti-CGRP was 62.9 and 57.9%, respectively. LOCF analyses confirmed these findings. No serious adverse events (AEs) were recorded and only two patients discontinued treatment due to AEs. CONCLUSIONS Difficult-to-treat CM patients who discontinued BTX-A and received anti-CGRP mAbs showed a substantial clinical improvement in migraine-related outcomes. Switching to an anti-CGRP mAb appears to be a viable option in patients with insufficient response after the first 2 cycles with BTX-A. The appropriate variables, cut-offs, and timing to define ineffectiveness and the best time to switch or combine therapies for difficult-to-treat CM need to be investigated further.
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Affiliation(s)
- Luigi Francesco Iannone
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Davide Fattori
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy
| | - Martina Marangoni
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy
| | - Silvia Benemei
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Alberto Chiarugi
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
| | - Pierangelo Geppetti
- Section of Clinical Pharmacology and Oncology, Department of Health Sciences, University of Florence, Viale Pieraccini 6, Florence, Italy.
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy.
| | - Francesco De Cesaris
- Headache Center and Clinical Pharmacology Unit, Careggi University Hospital, Florence, Italy
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Argyriou AA, Mitsikostas DD, Mantovani E, Vikelis M, Tamburin S. Beyond chronic migraine: a systematic review and expert opinion on the off-label use of botulinum neurotoxin type-A in other primary headache disorders. Expert Rev Neurother 2021; 21:923-944. [PMID: 34289791 DOI: 10.1080/14737175.2021.1958677] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Botulinum neurotoxin type-A (BoNTA) is licensed for the treatment of chronic migraine (CM), but it has been tested off-label as a therapeutic choice in other primary headaches (PHs). We aimed to provide a systematic review and expert opinion on BoNTA use in PHs, beyond CM.Areas covered: After providing an overview on PHs and mechanism of BoNTA action, we report the results of a systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, of BoNTA therapeutic trials in PHs beyond CM. Studies and results were reviewed and discussed, and levels of evidence were graded. We also collected data on relevant ongoing trials.Expert opinion: Although there are contradictory findings on PHs other than CM, BoNTA may represent a therapeutic option for patients who do not respond to conventional prophylactic treatments. Based on limited available evidence, BoNTA may be considered in refractory tension-type headache, trigeminal autonomic cephalalgias, primary stabbing headache, nummular headache, hypnic headache, and new daily persistent headache, after the primary nature of cephalalgia has been documented and other drugs have failed. Experienced physicians in BoNTA treatment are required to guide the therapeutic protocol for each patient to optimize good and safe outcomes.
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Affiliation(s)
- Andreas A Argyriou
- Headache Outpatient Clinic, Department of Neurology, Saint Andrew's State General Hospital of Patras, Greece
| | - Dimos-Dimitrios Mitsikostas
- 1st Department of Neurology, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Elisa Mantovani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | | | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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Silvestro M, Tessitore A, Scotto di Clemente F, Battista G, Tedeschi G, Russo A. Additive Interaction Between Onabotulinumtoxin-A and Erenumab in Patients With Refractory Migraine. Front Neurol 2021; 12:656294. [PMID: 33897608 PMCID: PMC8060469 DOI: 10.3389/fneur.2021.656294] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/23/2021] [Indexed: 01/17/2023] Open
Abstract
In the last decade, notable progresses have been observed in chronic migraine preventive treatments. According to the European Headache Federation and national provisions, onabotulinumtoxin-A (BTX-A) and monoclonal antibodies acting on the pathway of calcitonin gene-related peptide (CGRP-mAbs) should not be administered in combination due to supposed superimposable mechanism of action and high costs. On the other hand, preclinical observations demonstrated that these therapeutic classes, although operating directly or indirectly on the CGRP pathway, act on different fibers. Specifically, the CGRP-mAbs prevent the activation of the Aδ-fibers, whereas BTX-A acts on C-fibers. Therefore, it can be argued that a combined therapy may provide an additive or synergistic effect on the trigeminal nociceptive pathway. In the present study, we report a case series of 10 patients with chronic migraine who experienced significant benefits with the combination of both erenumab and BTX-A compared to each therapeutic strategy alone. A reduction in frequency and intensity of headache attacks (although not statistically significant probably due to the low sample size) was observed in migraine patients treated with a combined therapy with BTX-A and erenumab compared to both BTX-A and erenumab alone. Moreover, the combined therapy with BTX-A and erenumab resulted in a statistically significant reduction in the symptomatic drug intake and in migraine-related disability probably related to a reduced necessity or also to a better responsiveness to rescue treatments. Present data suggest a remodulation of current provisions depriving patients of an effective therapeutic strategy in peculiar migraine endophenotypes.
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Affiliation(s)
| | | | | | | | | | - Antonio Russo
- Department of Advanced Medical and Surgical Sciences, Headache Centre, University of Campania “Luigi Vanvitelli, ” Naples, Italy
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